1. Assessing and treating bradycardia Workshop
Version: Jun 2016

2. Learning outcomes At the end of this workshop you should be able to:
recognise when bradycardia is present
identify different degrees of heart block
describe how to treat bradycardia
list the indications for cardiac pacing
explain the methods available for cardiac pacing
demonstrate how to apply non-invasive, transcutaneous electrical pacing safely and effectively

3. Conducting system

4. QRS Complex

5. How to read a rhythm strip1.
Is there any electrical activity with a pulse?

6. How to read a rhythm strip1.
Is there any electrical activity with a pulse? 2.
What is the ventricular (QRS) rate? 3.
Is the QRS regular or irregular? 4.
Is the QRS width normal (narrow) or broad?
Describe the rhythm on this basis.
Continue further only if you are sure that you can see atrial activity.

7. How to read a rhythm strip1.
Is there any electrical activity with a pulse? 2.
What is the ventricular (QRS) rate? 3.
Is the QRS regular or irregular? 4.
Is the QRS width normal (narrow) or broad? 5.
Is atrial activity present?
(If so, what is it: P waves? Other atrial activity?) 6.
How is atrial activity related to ventricular activity?

8. Bradycardia algorithm Includes rates inappropriately slow for haemodynamic state

9. What action will you take?
Case study
Clinical setting and history
60-year-old man referred to admissions unit by GP
Long history of heart disease, details uncertain
Feeling light-headed and breathless
Clinical course
ABCDE
A : clear
B : spontaneous breathing, rate 18 min-1 , SpO2 96%
C : looks pale, P 45 min-1, BP 90/50 mmHg, CRT 3 s
Initial rhythm?
D : alert, glucose 4.5 mmol L-1
E : nil of note, normothermic
What action will you take?

10. Case study (continued)
Clinical course
no response to atropine
patient becomes more breathless, cold, clammy and mildly confused
change in rhythm
ABCDE
A : clear
B : spontaneous breathing, rate 24 min-1
widespread crackles on auscultation, SpO2 89%
C : looks pale, HR 35 min-1, BP 80/50 mmHg, CRT 4 s
D : responding to verbal stimulation
E : nil of note
What will you do now?

11. Case study (continued)
request expert help
prepare for transcutaneous pacing
consider percussion pacing as interim measure
confirm electrical capture and mechanical response once transcutaneous pacing has started

12. Case study (continued)
Atropine
Indication
symptomatic bradycardia
Contraindication
do not give to patients who have had a cardiac transplant
Dose
500 mcg or 600 mcg IV (depending on local availability), repeated every min to maximum of 3 mg
Actions
blocks vagus nerve
increases sinus rate
increases atrioventricular conduction
Side effects
blurred vision, dry mouth, urinary retention
confusion

13. Case study (continued)
Adrenaline
Infusion of 2-10 mcg min-1 , adjusted according to response
Other considerations:
OR Isoprenaline infusion 5 mcg min-1 as starting dose
OR Dopamine infusion 2-5 mcg kg-1 min-1 13

14. Any questions?

15. Summary bradycardia and different degrees of heart block
how to treat bradycardia
the indications for cardiac pacing
the methods available for cardiac pacing
non-invasive, transcutaneous electrical pacing safely and effectively

16. Advanced Life Support Level 2 Course Slide set
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© Australian Resuscitation Council (June 2016)

17. Additional Slides